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AHN 577 > Infectious Disease > Flashcards

Infectious Disease Flashcards

1
Q

Volume of distribution

A

Drug must reach the sites of infection at adequate concentrations

Factors: Lipid solubility, tissue penetration, blood flow to tissues, pH, plasma protein binding

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2
Q

Tetracyclines have…

A

Great distribution to the tissue, do not stay in the blood stream. Not good to treat blood stream infections

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3
Q

Metabolism

A

Most are metabolized in the liver

CYP450: Macrolides, rifampin, sulfonamides…

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4
Q

Elimination

A

Renal and non renal

Some drugs: Vancomycin, zosyn need different dosing based on GFR

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5
Q

Absorption

A

Many routes of intake

IM, inhalation, IV, PO, Intraperitoneal, Intrathecal

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6
Q

Agents that are active against the cell wall…

A

B-lactams, Vancomycin, Daptomycin, Telavancin, Azoles

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7
Q

Antibiotics that are protein synthesis inhibitors…

A

Tetracyclines (3oS)
Macrolides, clindamycin, chloramphenicol, synercid (5oS)
Fluoroquinolones (DNA girasse, Topoisomerase)
Rifamycins (RNA polymerase)
Linezolid (Other ribosomal agents)

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8
Q

Antibiotics that are cationic detergents that dissolve the cell wall…

A

Polymyxins

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9
Q

Antibiotics that inhibit free radical formation…

A

Metronidazole

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10
Q

Antimicrobial resistance

A

Drug enzymatic inactivation
Altered target site
Decreased permeability of antibiotic into cell

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11
Q

What is bacteriostatic?

A

Inhibits growth and replications

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12
Q

What is bactericidal?

A

Cause bacterial cell death

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13
Q

MIC?

A

Minimum Inhibitory Concentration (for bacteriostatic)

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14
Q

MBC?

A

Minimum Bactericidal Concentration

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15
Q

Concentration dependent antibiotics..

A

Peak matters, time above the MIC doesn’t matter.

Aminoglycosides, Daptomycin, Flouroquinolones

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16
Q

Time dependent killing

A

More time above MIC, the better they kill. Peak doesn’t matter.

B-Lactams
Linezolid

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17
Q

A combination of concentration and time dependent killing

A

Vancomycin, Macrolides, Tetracyclines, azoles

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18
Q

B-Lactam antibiotics properties

A

Inhibit cell wall synthesis
Bactericidal
Time-dependent killing

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19
Q

B-Lactam antibiotics

A

Penicillins
Cephalosporins
Carbapenems
Monobactams

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20
Q

Penicillin antimicrobial spectrum

A

Gram positive
Primarily Streptococci

Gram negative, very few
Neisseria Meningitidis

Drug of choice for:
Actinomyces (found in mouth)
Syphillis (T. Pallidum)`

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21
Q

“Anti-staphylococcal” penicillins

A 
Methicillin
Oxacillin
Nafcillin
Dicloxacillin
Cloxacillin

Mostly for MSSA
Soft tissue/skin infections

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22
Q

Gram negative rods SPACE bugs…

A 
S-Serratia, Klebsiella, Enterococcus
P-Proteus vulgaris or Pseudomonas
A-Acromobacter or Acinetobacter
C-Citrobacter
E-Enterrobacter
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23
Q

“Low resistance” GNR…

A

Aminopenicillins

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24
Q

Aminopenicillin antimicrobial spectrum…

A

Gram negative with “low resistance” enterobacteriacae
H. Influenzae

Food-derived:
Listeria (DOC)
Salmonella and Shigella

Gram +, Streptococci and enterococci

Better anaerobic coverage

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25
Q

Extended spectrum penicillins

A

Carboxypenicillins (Ticarcillin)
Ureidopenicillins
(Piperacillin)

Rarely used as single agents in US

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26
Q

Extended spectrum antimicrobial spectrum

A

Gram negative, increased activity including pseudomonas
Gram Positive, overall less, but still effective
Excellent anaerobic activity

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27
Q

B-Lactamase inhibitors

A

Clavulanic acid
Sulbactam
Taxobactam

Not used as single agents in the US

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28
Q

Cross-reactivity with other B-Lactams

A

1st gen. cephalosporins 5-10%
2 & 3 gen. Cephalosporins 1-5%
Carbapenems 1-5%
Monobactams, rare

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29
Q

How many generations of Cephalosporins

A

5

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30
Q

The first generations have only…

and as you move to the 5th generations they become more…

A

Gram positive

Gram negative also

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31
Q

Colonization is…

A

the presence and replication of micro organisms without tissue invasion and/or damage

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32
Q

Normal Flora of the nasopharynx

A 
Streptococci
Haemophilus
Neisseria
Mixed anaerobes
Candida
Actinomyces
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33
Q

Normal Flora of the Skin

A 
Staphylococci
Streptococci
Corynebacteria
Proprionibacteria
Yeasts
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34
Q

Normal Flora of the upper bowel

A

Enterobacteriaceae
Enterococci
Candida

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35
Q

Normal Flora of the Lower bowel

A

Bacteroides
Bifidobacteria
Clostridium
Peptostreptococci

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36
Q

Normal flora of the vagina

A 
Lactobacilli
Streptococci
Corynebacteria
Candida
Actinomyces
Mycoplasma hominid
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37
Q

Innate immune system of eyes

A

Lysozyme in tears kills gram positive bacteria

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38
Q

Innate immune system of the nose

A

Removal of particles by turbinates and humidification

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39
Q

Innate immune system of the upper airway

A

Mucus and cilia capture organisms and remove them

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40
Q

Innate immune system of the skin

A

physical barrier

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41
Q

Innate immune system of the stomach

A

Stomach acid kills ingested pathogens

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42
Q

innate immune system of the bowel

A

Competition and toxic products from intestinal flora

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43
Q

innate immune system of the bladder

A

Flushing action of urinary flow removes organisms

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44
Q

innate immune system of the vagina

A

Low vaginal pH from lactobacilli prevents colonization by pathogens

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45
Q

Innate immune system of the whole body

A

molecular and cellular defense
Patter recognition molecule
Neutrophils
Macrophages

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46
Q

Infection is an invasive presence and replication of micro-organisms accompanied by…

A

Local cell injury/death
Secretion of toxins
Host immune response

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47
Q

Culture interpretation is dependent upon:

A

Complete clinical picture
Method of collection
Gram stain results
Cellular evidence

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48
Q

Most likely cause of contamination…

A

Poor collection technique

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49
Q

Gram positive Cocci

A

Staphylococcus
Streptococcus
Enterococcus

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50
Q

Gram positive Rods

A

Corynebacterium
Bacillus
Listeria

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51
Q

Gram Negative Cocci

A

Neisseria

Moxorella catarrhalis

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52
Q

Gram negative rods

A 
Enterobacteriaciae
Normal gut flora
Vibrio
Shigella
Salmonella
Pseudomonas
Hemophilus
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53
Q

Anaerobes

A

Gut flora
Actinomyces
Bacteriodes

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54
Q

Mycobacteria

A

TB

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55
Q

Fungi

A

Candida

Aspergillus

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56
Q

Viruses

A

Herpesvirus family
Adenovirus
Influenza
Coxsackievirus

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57
Q

Rickettsia

A

Rocky Mountain Spotted Fever

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58
Q

Parasites

A

Giardia Lamblia

Pneumocystis Jiroveci

59
Q

Spirochetes

A

Treponema Pallidum

60
Q

Principles of antimicrobial Coverage

A

The use of any antibiotic promotes resistance
Broad spectrum is used- promotes resistance to both normal and pathogenic flora
Narrow spectrum- confines resistance to fewer organisms

61
Q

Therapeutic considerations of antimicrobial coverage

A

Identify whether infection is present

Choose the narrowest spectrum, least toxic, least invasive, and least expensive medication that is the most effective

62
Q

Primary interventional concepts of antimicrobial coverage

A

Observation without antibiotics
Preventive/Prophylactic therapy- patients with artificial heart valve who need dental work
Empiric therapy- what we use while we await cultures
Specific therapy- tailored to the cultures

63
Q

Meningitis common bacterial organisms

A

Strep Pneumonia
Neisseria meningitidis

Gram negative, group B strep more common in > 50 years

64
Q

Meningitis common viral organisms

A

HSV
EBV
Varicella Zoster
Coxsackievirus

65
Q

Meningitis clinical manifestations

A 
HA and fever
AMS
Nuchal rigidity
Positive Kernig and Brudzinskis
May also see photophobia and seizures
66
Q

Kernigs sign

A

Hip flexion on supine patient, hamstrings contract and they are unable to extend their knees

67
Q

Brudzinskis sign

A

Head flexion causes spontaneous hip and knee flexion

68
Q

Meningitis diagnosis

A

CT scan
CSF for gram stain, culture, AFB
Blood cultures

CT must be done before LP because you can cause herniation is symptoms are caused by space occupying lesion

69
Q

Bacterial Meningitis LP

A

Leukocytes- 100-50000 PMN
Protein- 100-500
Glucose- Low

70
Q

Viral Meningitis LP

A

Leukocytes- less than 1000 MN
Protein 50-200
Glucose normal or high

71
Q

Viral encephalitis LP

A

Leukocytes- less than 1000 PMN early then MN
Protein 50-200
Glucose- normal or high

72
Q

TB meningitis LP

A

Leukocytes- 10-500 lymphocytes
Protein- 100-500
Glucose Low < 40

73
Q

Brain Abscess

A

Leukocytes- 10-200 lymphocytes
Protein 100-500
Glucose Normal

74
Q

Meningitis treatment

Antibiotics

A

Need bactericidal medication
Drugs that readily cross the BBB

Dexamethason prior to abs, then Q 6h

Ceftriaxone + Vancomycin (18-50 y.o community acquired)
Add ampicillin if > 50
Continue for 10-14 days

75
Q

Meningitis treatment other

A

Avoid volume overload
seizure precautions
monitor for cerebral edema
ID consult

76
Q

If meningococcal meningitis is diagnosed

A

Prophylactic treatment is indicated for anyone with close contact

College setting

77
Q

Viral meningitis treatment

A

Self-limiting

Treatment directed towards the specific virus

78
Q

Endocarditis risk factors

A

Native heart valve disease in those > 60 years
Prosthetic heart valves
IV drug Abuse (tricuspid valve)
Bacteremia following dental (streptococci), pulmonary, urologic or lower GI procedures

79
Q

Endocarditis common organisms

A 
S. Aureus is the MOST COMMON!!!
Streptococci
Enterococci
Coag negative staphylococci
HACEK organisms (pg 1458 CMDT)
Fungi
80
Q

Endocarditis Clinical manifestations

A 
Persistent fever- days to weeks
Malaise
Fatigue
Anorexia
Arthralgias/Myalgias

New or worsening murmur
Petechiae, Osler (tender on pads fingers and toes)/janeway nodes (Contender erythematous macule on palms and feet), splinter hemorrhages
Roth spots
Splenomegaly

81
Q

What are Osler nodes

A

Tender nodules on the pads of the fingers and toes

82
Q

What are Janeway nodes?

A

Nontender erythematous macule on palms of the hands and soles of the feet

83
Q

How to diagnose Endocarditis

A

BC x 3 at least an hour apart
TTE & TEE
CXR
Modified Duke criteria

84
Q

What is the modified duke criteria?

A

Clinical criteria
2 major, 1 major + 3 minor or 5 minor

Major criteria
Positive blood culture for characteristic organism or persistently positive
Echocardiographic identification of a valve related mass or abscess
New Valvular regurgitation

Minor criteria
Predisposing heart lesion or IV drug
Fever
Vascular lesions
Immunological phenomena
Microbiologic evidence
Echocardiographic findings consistent with but not diagnostic of endocarditis
85
Q

Endocarditis treatment

A

Empiric treatment with Ceftriaxone and Vancomycin

Then tailor therapy for culture

ID and Cardiology consult
Surgical intervention if treatment failure after 7-10 days or acute HF

86
Q

Tailored treatment of endocarditis

A

Streptococci -PCN or Ceftriaxone
Enterococci- PCN/Ampicillin and Gentamycin
MSSA/MRSA- Nafcillin/Oxacillin or Cefazolin; Vancomycin/Daptomycin
Coag negative staph (Prosthetic valves)- Vancomycin, Rifampin, Gentamycin
HASEK- Ceftriaxone

87
Q

Dental prophylaxis

A

Amoxicillin is preferred

Alternative for PCN allergy is Clindamycin, Cephalexin, Azithromycin

88
Q

Endocarditis complications

A

Myocardial abscess
Rhythm disturbances
Embolization- septic emboli to brain, coronary arteries, spleen
TV endocarditis- septic pulmonary emboli with IVDA

89
Q

CLABSI risk factors

A

Healthcare associated infection

Central lines placed in the femoral artery- 72%

90
Q

CLABSI clinical manifestations

A

Fever
Purulent drainage from the site
No other readily available source

91
Q

CLABSI common organisms

A 
Coag negative staph (most common)
MRSA
E. Faecium
Pseudomonas
Acinetobacter
Candida
92
Q

CLABSI antibiotic empiric treatment

A

Ceftazidine or Cefepime plus Vancomycin

93
Q

CLABSI management

A

ABX
Remove lines
Culture tip
Blood cultures

94
Q

Pneumonia Types

A 
Community associated (CAP)
Ventilator associated (VAP)
Hospital associated (HAP)
Healthcare associated (HCAP)
95
Q

Pneumonia common organisms

A

CAP- S. Pneumonia (most common), Klebsiella, S. Aureus, H. Influenzae
VAP/HAP/HCAP- MRSA (most common), P. Aeruginosa (often MDR), Acinetobacter, E. Coli, Enterobacter

Atypical- M. Pneumonia, Legionella
Viral

96
Q

Pneumonia clinical manifestations

A
  1. CAP- fever, cough, may have sputum or dyspnea, chills, diaphoresis, pleurisy, anorexia, HA, Fatigue, Myalgias
  2. VAP/HAP/HCAP- the presence of a new infectious infiltrate on CXR with new onset fever, sputum production, leukocytosis, and reduced SaO2
  3. PE findings- Tachypnea, ST, Crackles, or diminished breath sounds
97
Q

Urinary antigen for S. pneumoniae and legionella pneumophilia-

A

reserved for severe cases of CAP in the ICU

98
Q

CAP management

outpatient, healthy, no recent abx

A

a. Macrolide or doxycycline

99
Q

CAP management outpatient with comorbid conditions

A

a. Resp. FQ (Levaquin)

b. PO beta lactam and macrolide

100
Q

CAP management

Inpatient, nonicu

A

a. IV betalactam + macrolide

b. Resp. FQ (Levaquin)

101
Q

CAP management

inpatient, ICU

A

a. IV beta lactam + macrolide

b. IV beta lactam + Resp FQ

102
Q

HAP treatment

A
  1. Use 2 drugs if (antipseudo + a Fluroquinalone or an aminoglycoside)
    a. prior IV abx last 90 days
    b. Structural lung disease
    c. Septic shock or MV need
  2. AntiMRSA coverage is required if…
    a. Staph isolates
    b. Prior IV ABX last 90 days
    c. Septic shock or MV
103
Q

HAP antipseudomonal treatment

A
  1. Antipseudomonal beta lactam
    a. Zosyn
    b. Cefepime
    c. Meropenem
    d. Imipenem
    Plus 1 of the following:
  2. Resp. FQ
    a. Levofloxacin
    b. Ciprofloxacin
  3. AG
    a. Gentamycin
    b. Tobramycin
    c. Amikacin
104
Q

HAP MRSA treatment

A
  1. Antipseudomonal beta lactam
    a. Zosyn
    b. Cefepime
    c. Meropenem
    d. Imipenem

Plus Add 1:
Vancomycin
Linezolid

105
Q

VAP treatment

A
  1. Antipseudomonal ABX needed if
    a. > 10% GNR resistance
    b. Structural lung disease
    c. Risk factors for MDR VAP
  2. MRSA ABX needed if
    a. > 10-20% isolates MRSA
    b. Risk factors for MDR VAP
106
Q

VAP antipseudomonal treatment

A
  1. Antipseudomonal beta lactam
    a. Zosyn
    b. Cefepime
    c. Meropenem
    d. Imipenem
    Plus 1 of:
    a. FQ: Levo, Cipro
    b. AG: amikacin, gent. Tobra
    c. Polymyxin: Colistin
107
Q

VAP MRSA treatment

A
  1. Antipseudomonal beta lactam
    a. Zosyn
    b. Cefepime
    c. Meropenem
    d. Imipenem
    Plus 1 of:
    Vancomycin or Linezolid
108
Q

Risk factors for MDR

A

Antimicrobial therapy in previous 90 days
Current hospitalization of > 5 days
Immunosuppressive disease and or therapy

Other:
Previous hospitalization within last 90 days
Resides in nursing home
Home infusion therapy
Chronic dialysis
Home wound care
Family members with MDR
109
Q

Urinary tract infection risk factors

A

Indwelling catheters

females

110
Q

UTI common organisms

A
  • E. Coli, Klebsiella, Proteus miribilis

+ S. saprophytic, E. Faecalis, GB strep

111
Q

Uncomplicated cystitis ABX

A 
Nitrofurantoin
Bactrim
Fosfomycin
Fluoroquinolones
AMX
Cefdinir, Cefaclor, Cefpodoxime
112
Q

Uncomplicated pyelonephritis ABX

A 
Fluoroquinolones
Levofloxacin
Ciprofloxacin
Bactrim
Aminoglycosides +/- ampicillin
Cephalosporin or penicillin +/- ahminoglycosides
Carbapenems
113
Q

Complicated cystitis ABX

A

Fluoroquinolones
Levofloxacin
Ciprofloxacin
Ampicillin or amoxicillin

114
Q

Complicated pyelonephritis ABX

A

Fluoroquinolone plus cephalosporin or penicillin or carbapenem

115
Q

Skin and soft tissue infections risk factors

A

Invasive devices
Surgical procedures
Debilitated skin integrity
Diabetics

116
Q

Skin and soft tissue infection clinical presentation

A

Rapidly spreading area of erythema
Culture the site if appropriate
Can lead to sepsis
Assess for necrotizing fasciitis if areas of necrosis appear

117
Q

Skin and soft tissue infection common organisms of necrotizing fasciitis

A

V. Vulnificis
S. Pyogenes
Aeromonas
Clostridiums

118
Q

Skin and soft tissue infection ABX therapy for non purulent infections

A

Cellulitis

  • penicillin
  • ceftriaxone
  • cefazolin
  • clindamycin

If severe: rule out nec fasc. vancomycin plus zosyn

119
Q

Skin and soft tissue infection treatment

A

May require surgical debridement

120
Q

Skin and soft tissue infection ABX therapy for purulent infections

A

Mild- just I&D

Moderate- I&D plus C&S
-Bactrim or doxycycline

Once C&S:
MRSA- Bactrim
MSSA- Cephalexin or Dicloxacillin

Severe- I&D plus C&S

  • Vancomycin
  • Daptomycin
  • Linezolid
  • Televancin
  • Ceftaroline
Once C&amp;S:
MSSA use:
-Nafcillin
-Cefazolin
-Clindamycin
121
Q

Defined ABX therapy for severe non purulent soft tissue infection

A

Streptococcus pyogenes- Penicillin plus clindamycin

Clostridial sp. - penicillin plus clindamycin

Vibrio vulnificus- Doxycycline plus ciprofloxacin

Polymicrobial
Vanco plus Zosyn

122
Q

Clinical manifestations of necrotizing fascitis

A 
Erythema
Marked edema
SEVERE tenderness
Bullae formation
Compartment syndrome
Systemic symptoms- fever, septic shock
123
Q

ABX coverage for nec. fasc

A

Vancomycin and Zosyn

Doxycycline and Ceftazidime are essential with a high degree of suspicion for Vibrio vulnificus

Surgical debridement is primary treatment

124
Q

Surgical site infection risk factors

A 
severity of illness
type of surgery
length of surgery
comorbidities
age
steroids
other infected sites
125
Q

Surgical site infection clinical manifestations

A

Fever
evidence of local infection- redness, drainage, poor healing
(Culture drainage)

126
Q

Surgical site infection treatment

A

Determined by gram stain and culture

Treat for common skin flora in that area

127
Q

Osteomyelitis risk factors

A

Diabetes and diabetic foot wounds

Injured bone that has lost vascularity- no longer accesses to blood borne defenses

128
Q

Osteomyelitis common organisms

A

S. Aureus

Coag negative staphylococcus

129
Q

Osteomyelitis management

A

Orthopedic referral
MRI
Culture of open site or surgical bone biopsy
Drainage is the central concept of therapy- ABX are an adjunct
may require many months of therapy

130
Q

C. Diff colitis risk factors

A

Antibiotic use- primarily fluoroquinolone, clindamycin and cephalosporins
Age > 65
Hospitalization
Severe illness

131
Q

C. Diff

A

Anaerobic gram + spore forming bacillus

132
Q

C. Diff managment

A

Prevention of transmission is essential

133
Q

C. Diff ABX

A

Metrondiazole
Add vancomycin PO for severe disease
10-14 days

134
Q

C. Diff clinical manifestations

A 
Colitis with diarrhea
Watery, foul smelling
abdominal pain/crampin
fever
anorexia
nausea
malaise
fever
shock
leukocytosis
renal failure
135
Q

C. Diff treatment

A

DC offending antibiotics
GI/ID consult
ABX
Fecal transplants

136
Q

Fever of unknown origin definition

A

Fever > 101 for at least 3 weeks

Definitive cause occult despite complete workup

137
Q

FUO common etiologies

A 
Infection
malignancy
autoimmune disease- 22%
Drug induced
Granulomatous disease
Any inflammatory process- surgery, burns, trauma
Factious fever
138
Q

FUO treatment well appearing

A 
Stop non essential meds
CBC
BMP
LFT
UA
Radiographs as needed
Observation
139
Q

FUO treatment is appearing ill

A 
Admit to hospital 
Stop non essential meds
LFT
hepatitis panel
BC
UA
CSF culture
CRP
140
Q

FUO workup for suspected infectious cause

A

Cultures
CSF studies
CRP/ESR
Empiric antibiotics

141
Q

FUO workup for suspected oncologic cause

A 
Uric acid
Lactate dehydrogenase
Ferritin
Peripheral smear
Chest radiograph
Hold steroids
142
Q

FUO workup for suspected autoimmune cause

A 
Antinuclear antibody
Rheumatoid factor
C3, C4, CH50
Thyroid function
CRP
ESR
Ferritin
143
Q

FUO workup for suspected immunodeficiency causes

A

immunoglobulins
lymphocyte markers
consider antibody titers to known vaccinations
HIV

AHN 577 (4 decks)

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